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0085 MEMORIAL DRIVE - CAMP NAUMKEAG The Commonwealth of Massachusetts i Board of Building Regulations and Standards I (>It '\Il'NI('ll'.\I.II1 MaSSaChLlsetlS State Building Code. 780 CMR, 7"' edition list a, Building Permit Application To COuSIrtICL Repair. Reno\ate Or Demolish a Rrri.,rd hinitai c Orr- urT, u-Fomih, Duelling /. 'rgal' This Section For Official Use Only Building Permit Number: Dare Applied: Signature: �- e it ng conumissume nspectur of Buildings Dale x t ) SECTION 1: SITE INFORMATION V 1.1 Pro erly :Yddress:: L L2 Assessors Map & Parcel Numbers ��w-4? - 1.1a Is this an accepted street? yes no Nlap Number Parcel Numhei 1.3 Zoning Information: 1.4 Property Dimensions: 7nnine niacin Proposed Use Lot Area(sq f) FronIage (It) Ir1.5 Building Setbacks (ft) --^--- — _ _- — , j Front Yard Side Yards Rear Yard d Required Provided Required Provided Required Poolded ------------ 1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'' Municipal ❑ On site disposal s stem ❑ Public ❑ Private❑ Check if yes❑ P 1 Y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name (Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other Spec1ly:_7MN t Brief Description r Proposed Work': r'eef' 30sXNo C _— — _al I l SECTION 4: ESTIMATED CONSTRUCTION COSTS r Estimated Costs: hem (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee: $ Indic Ile how fee is determined: ❑Standard City/Town Application Fee 2. Electrical ❑$ T , otal Project Cost (item 6) x multiplier 3. Plumbing $ ?. Other Fees: $ 4. Mechanical (HVAC) $ List-. 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check .Amount: Cash :\nnnull: _ b. Total Project Cost: $ g00 ❑ Paid in Full 0 Outstanding Balance Due:____-J SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) i2 �' / `.Q N�2(" License Number Lxpnanon Duce Namc of CSL- IIuIJcr/ List CSI_ Tcpc Isce below) _ 4JJres Ty e Deschroon l l:mcstncieJ (up to 35.1N)U Cu. Irt.i R Resuieted 1&2 Family Dsselllon Sigi N Masonn Only RC Residential RoolijwCo\cnng Telerhone \b'S Residrniial Wmdo" and Sidnna — SF RrsiJemial Solid I'ncl I$mune :\ >>Irmc. Insi.ill.ni nu U lic.idcnti:d Demohwon 5.2 Registered Home Improvement Contractor (HIC) HIC Company Name or HIC Registrant Name Registration Numher Address Expiration Date Signature — Telephone S.F.. TTON 6: IVORKE S'.COMPENSATION !NSURANCE AM A VIT lNp.G.I....c. 152. § 25616)) J Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance the building permit. Signed Affidavit Attached'? Yes .......... No .......... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize az'ze g4ey- vr—l�� to act on my behalf, in all mauers relative to work authori y this building permit application. Si nature of4wner / Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Sinned under the pains and penalties of oerjury). NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and 1 10 R5, respectively. '. When substantial work is planned, provide the information below: Total flours area (Sq. Ft.) (including garage, finished base men Batt ics, decks or porcht Gross living area (Sq. Ft.) Habitable room count _ Number of fireplaces Number of bedrooms _ Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open _ ._--- 3. "Total Project Square Footage'* may be substituted for 'Total Project Cost' ACOR-Q. CERTIFICATE OF LIABILITY INSURANCE DATE 7122100" Y) n2zrznos PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Wholesale Retail Suppliers Compensation ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Corporation HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box Br:-5933 . ..___. _. .—. Boston MA 022845933 INSURERS AFFORDING COVERAGE �I NAIC# INSURED Rice Renl-i Ccnlel nL INsuRER A' `rJHOLE—�ALE`.RETAII_ SUPPLIERS _ Grand Rental Station INSURER B. 115 Cabot Sleet IN9URERC— Beverly MA '01915 INSURER.D. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REGUIREMIENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ODL r POLICY EFFECTIVE POLN:Y EXPIRATION LIMITS I.M.NSR- _ TYPEOFN§URANCE POLICY NUMBER GATE Y T Y __ _ GENERAL LIABILITY, DAMAGE TO ORENTE _ E DAMAGE TORENTEO E DOMMERC WL GENERAL LIABILITY I PREMISE$LEa Quy(gnceJ CLAIMS MADE OCCUR j MED EXP(My one person) 8 PERSONAL 3 ADV INJURY E GENERAL AGGREGATE E f --- _ PRODUCTS-COMP+ PAGG I-E_ - ICENLAGGREGATELIMITAPPLIESPER:I RO- PoucY�J PECT _j AUTOMOBILE UABILRY I COMBINED SINGLE LIMIT 3 (Ea xdew t) �MY AUTO _.— I ALL OWNED AUTOS BODILY INJURY S JI SCHEDULED AUTOS (Per PCRon) I —i HIRED AUTOS BODILY INJURY S (Per Aaamen0 NON-OWNED AUTOS -- - -- PROPERTY DAMAGE -- (Per eDDMenI) E � GARAGE LIABILm AUTO ONLY-EA ACCIDENT $ i ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ XCESSILI LIABILITY LIABILI EACH OCCURRENCE — E OCCUR �CLAIMS MADE AGGREGATE i — I E DEDUCTIBLE — 3 RETENTION 3 WC STATU- OTH- A WORKERS COMPENSATION AND -05 01i0112008 01J01121)09 :T A 0R1t LDNLa— EB—. EMPLOYERS'LLIABILITY \S`C r311L47 EL EACHACCIDENT S 100.000 SPECLLL PRWISIONS DLeIDwia Y EL.DISEASE_-POLICY LIMIT < 100.000 ANY PROPUETOR~TNEWEXECUTNE EL DISEASE-EA EMPLOVEEI 3 =on.x o OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECOLL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SECANCELLED BEFORE THE EXPIRATION OtY of Salem DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SD SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES___ AUTNORRCDREPRESENTATWE ACORD 25(2001108) B'ACORD CORPORATION 1988 J IMPORTANT If the certificate holder is an ADDITIONAL INSURED. the policy(es)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) o r�uR'E'�'�9'�'J�'�'�''��'M 1 M P O RTANT DO C U M E NT'''L'd'�'L'LLPLrLiI'L PLPLPLs�o 5 Certificate of Plante Resist�aixe 5 S REGISTRATION ISSUED BY 5 Date of Manufacture 5 APPLICATION o- /�u p 5 SNUMBER ' NoCHE�A° os�orvos C 5 X �r EVANSVILLE, INDIANA 47725 Order Number 5 5 F121.4 �� MANUFACTURERS OF THE FINISHED 368094 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 5 (or are inherently noninflammable) and were supplied to:692825 S 5 RICE RENTAL CENTER S 5 TAYLOR RENTAL CENTER#14978-4 115 CABOT STREET 5 5 BEVERLY MA 019155108 5 S 5 5 5 � 5 5 5 S 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 5 chemical and that the application of said chemical was done in conformance with California 5 S Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 5 The method of the FR chemical application is: 5 SSerial # 8025000(1) S Description of item cent ' S {g 5 5 P P(EP TOP 30W X 30 VL WW 5 5 S Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 lOHNBOYLE STATESVBLENC 1� 5 Signed: � 5 i 5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT-ANCHOR INDUSTRIES INC. 5 ' l7 cPrJ�rJ�rJ�cPrJ�cPrJcPcPr�r�cPcP[PrP�PrPrJ�cicPrJ�cP[PcPcPrJ�cPcP�P[.PrJ�rJ�rJ@PcPcPcPrJ�rJ�r1rJ� rJ�rJ�r.PrJ�rJ�rJ�rJ�rJ�rlcPcPrJ@PrJ�cPcPr.PrPrPrPcPr�rlcPrPrPrJ@PrJ� O y ,, IMPORTANT DOCUMENT. .. O clrJ�cPrJ@PcPrlcPcf@P�PrJ�cPcPcPcPJ �PLPL cPrJcPcPcPcPcPrJ�cPcPrJ�rJcP (] 5 Certif icate of �lalrte Resistance s 5 REGISTRATION 5 APPLICATION I�UCR�IR Date of Shipment 5 NUMBER 401 USTai INC.e 5 5 4 EVANSSSV✓✓ILLE, INDIANA 47725 Tent Identification 5 FI2 L4 MANUFACTURERS OF THE FINISHED 03873714 S 1j TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to:692825 S 5 RICE RENTAL CENTER 5 TAYLOR RENTAL CENTER#14978-4 115 CABOT STREET BEVERLY MA 019155108 5 5 Certification Is hereby made that: 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 chemical and that the application of said chemical was done in conformance with California 5 S5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109. 5 r1„ Serial # E025300cn 5 Description of Item certified: 5 FIESTA EXPANDABLE MIDDLE 5 30WXIO WHITE VBJYL 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective,For The Life Of The Fabric 5 EN BOYLE STATESVI LE NC Signed: 5 L j SPEaAL EVEHfS mrim-ANOM UID MMIES ING O cPrJ@PcPcPrJrlcPrPcPcPcPcPcPrJ�cPrJ�rJ@PrJ�rJ@PrlrJ�cPcPcPrJ@PcPrJcPcPcPrPcPPcPrJ@PcPrPrPcPcPcPcPcPcPcP�1�rJ@PcPcl�cPcPrlrl�PrJcPcPrJ@Pr�PrJ@PrJ@PcPrJ� O ° �'` n`nu�'�u�'�'u�'u��'�'u 1 M P O RTANT DOCUMENT RIPM02�����L3giy � o I 5 Cert f icatJe ' of Flan'?e Resistance S 5 REGISTRATION ISSUED BY 5 5 APPLICATION o Date of Manufacture 5 5 NUMBER s I j�MOM050M5 5 EVANSVILLE, INDIANA 47725 Order Number e5 SF121.4 MANUFACTURERS OF THE FINISHED 368094 S 5 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to: 5 692825 5 5 RICE RENTAL CENTER 5 5 TAYLOR RENTAL CENTER#14978-4 S 115 CABOT STREET 5 BEVERLY MA 019155108 5 S 5 5 5 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 chemical and that the application of said chemical was done in conformance with California 5 S Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 55 The method of the FRI chemical application is: 5 Serial # 8020560C(4) 5 5 5 Description of item certified: TENT WAL610'X40'VL WHI4/CA F121.4 JOHN BOYLE STATESVW,E NC 1 5 S 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric S 5 IOHNBOYLE STATESVILLENC Signed: _.� g�� r5 rj Name of Applicator of Flame Resistant Finish TENT DEPARTMENT.ANCHOR INDUSTRIES INC. r O u�cP�Pr�urJ�cPcPu�rJrJ�cncnrJcPcPcncPu�cnu�uu211:PcPu@nrJ�u�u�[PcPu�u�rJ�rJ�u�rJ�rJ�cn cPcPurJ�u�r�rJ�cPucP[Pu@PcPu�c nu�u�cPcPcnrJ�u@n�nu�u�u�cn !7 IMPORTANT DOCUMENT �sLnLns�LPuPLLP�Lns�LpupL� o 5 5 5 Certificate Of ff lamp Rva'5tance S SREGISTERED Q u4 ISSUED BY Date of Manufacture 5 e5 APPLICATION �/yy���ES R / / 5 NUMBER > 1�0 USieiESlxc� 2 26 99 5 �2 EVANSVILLE, INDIANA 47711 Order Number 5 5 F121 .4 vto 216154 5 ctl• MANUFACTURERS OF THE FINISHED 5 5 TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated S 5 (or are inherently noninflammable) and were supplied to: 5 RICE NTAL NTER ImTAYLORE ENTALECENTER 5 115 CABOT STREET r 5 BEVERLY MA 019155108 55 Certification is hereby made that: 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 chemical and that the application of said chemical was done in conformance with California Fire Marshal Code, equal to exceeds NFPA 701, CPAI 84, ULC 109. 5 5 The method of the FR chemical application is: e5 5 Serial M: 8105960 (0004) S5 Description of item certified: 5 TENT WAL 6-10 X 30 VL W W 3/CA 5 5 5 5 Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric 5 5 TATESVLE, NC Signed: IL _'� 0� 5 5 Name of Applicator of Flame Resistant Finish TENT DEPARTMENT—ANCHOR INDUSTRIES INC. e5 O cPrJ�rJr�cPrJ�r?PrJrJ�rJ�rJ�rJ�cPrJ�rJrJ�rJ�r?�rJ�rJ�rJ�rJ@PrJ�rJ�rJ�rJ�rJ�rJ�rJ�r?Prlr�r�rJ�rJ�rJ�r?�cPrJ�r?.Pr�rJcPrJ�rJ�rlrJ�rJ�cPrJrJ�rJrJ�rJrJrJ�rJ�r?lrJ�r?PrJ�r?PcPrJr�rJ�cPrJ�r1rJ�rJrJrJ�cPcPrJ�rJ�rJ�rJ�cPrJr?PO]